Kotaro Tsuboi, MD
Assistant Professor of Ophthalmology
Motohiro Kamei, MD, PhD
Professor and Chair of Ophthalmology
Aichi Medical University
The “Video Surgical Complications-What Would You Do?” session was moderated by Dr. Kourous A. Rezaei from Illinois Retina Associates in Chicago.
The esteemed panelists were Drs. Andrew Chang, Ehab N El Rayes, Andre V Gomes, Frank H Koch, Barbara Parolini, Elliott H Sohn, Asheesh Tewari and Daniele Tognetto.
The first video was presented by Dr. Asheesh Tewari. He demonstrated how to elegantly manage suprachoroidal migration of silicone oil (SO).
Reoperation with vitrectomy, membrane peeling and SO injection was performed for a monocular patient with rubeotic glaucoma associated with proliferative diabetic retinopathy. During SO injection, suprachoroidal SO infusion was noted as a large choroidal elevation with hemorrhage. SO injection was stopped and an external cut down was immediately performed. A fluid mixture of oil and heme was evacuated from the suprachoroidal space. The SO injection was then resumed to safely and completely fill the vitreous cavity.
Dr. Frank asked whether the choroidal elevation still existed after the external removal. Dr. Tewari responded that the choroidal wall was still elevated, but he did not worry about inadequate SO fill after resolution of the choroidal detachment, because in this case, the majority of the pathology was posterior.
Dr. Parolini inquired about the mechanism of suprachoroidal SO injection. Dr. Tewari speculated that the tip of the infusion cannula migrated into the suprachoroidal space from the vitreous cavity because due to hypotony.
Dr. Rezaei commented that during intraocular injections, the most important thing is to carefully inspect the tip to assure that the injection is entering the eye. If the injection of the material cannot be visualized, he recommends to avoid continuing to inject to prevent additional trouble.
The second video was from Dr. Andrew A. Chang, who demonstrated the management of the retinal incarceration into the vitreous cutter during retinal detachment surgery.
Dr. Chang performed a 23-G primary vitrectomy for a rhegmatogenous retinal detachment. When the subretinal fluid was aspirated from the pathologic small retinal break located superiorly, the retina entered the cutter. Proportional reflux was attempted, but the retina did not release. The break was enlarged. Diathermy was applied to the edge of the break, a posterior retinotomy was created, and fluid-gas exchange was performed. Subretinal hemorrhage was also removed, and photocoagulation was performed around the retinal break.
Dr. Sohn commented that disconnecting the aspiration line of the cutter and injecting BSS or gas into the line can release incarcerated retina. Dr. Rezaei recommended to keep the cutter turned on when using a vitreous cutter to aspirate from a break to avoid unintended suction of residual vitreous, which may result in retinal incarceration. It should also be noted that the tip of the cutter is larger than the tip of the aspiration needle, so aspiration with the aspiration needle is slower, but generally safer.
Dr. Rezaei also mentioned that other issues can occur, such as bleeding from the iatrogenic retinal break. In such circumstances, the first thing to do is to increase the IOP. Using perfluoron may also protect the macula from a subretinal clot. If there is submacular hemorrhage after fluid-gas exchange, it is not necessarily a terrible situation, because the blood is mobile and will be displaced during face down positioning.
Dr. Andre V. Gomes showed a nice technique to remove subretinal perfluoron. Dr. Gomes cut the tip of a 39-G parylene needle tip obliquely with scissors and made a bevel to easily penetrate the retina.
Dr. Gomes used the needle, beveled down, to pierce through the retina to easily remove the subretinal perfluoron bubble, which was located in the foveal region.
Dr. Rayes asked whether active aspiration was used, and whether all of the perfluoron was able to be removed. Dr. Gomes answered that both factors depend on the location of the subretinal perfluoron. If it is far from the macula, observation is a great option. The panelists asked whether there’s concern for additional damage related to the insert the cannula under the fovea. Dr. Gomes answered that OCT is helpful to preoperatively and postoperatively make the assessment and to discuss the risks with the patient. Dr. Gomes re-emphasized that this technique minimizes the damage to the retina.
Dr. Rezaei asked about the possibility of creating a focal retinal detachment to displace the subretinal perfluoron to minimize foveal damage. Dr. Parolini indicated that the perfluoron bubble may not move under the focal retinal detachment, and that there is risk of creating an iatrogenic macular hole (MH). The other panelists were also concerned about the risk of MH because the fovea was already compromised and very thin from the subfoveal perfluoron.
Dr. Daniele Tognetto presented a case of double perforation as a complication of a retrobulbar block. The case was of an aphakic, myopic monocular patient with an axial length of over 32 mm, undergoing glaucoma surgery. The surgeons noted at the start of the surgery that there was vitreous and iris prolapse from a corneal wound. After the anterior segment was addressed, they noted vitreous hemorrhage, subretinal hemorrhage and two retinal breaks inferiorly and temporally from the retrobulbar needle. Vitreous shaving and iridotomy were performed and subretinal fluid and hemorrhage were aspirated from the breaks.
The last presentation was from Dr. Ehab N El Rayes. He showed us three cases of how to manage hemorrhage during macular hole surgery.
The first case was hemorrhage that developed during ILM peeling. Hemostasis was successfully achieved by immediately increasing the IOP, and the ILM peel was extended to cover the retinal defect also.
The second case showed hemorrhage without retinal damage during ILM peeling, which can occur commonly from sheering of capillaries. IOP can be elevated if needed, and there is no need to worry.
The last case demonstrated the difficulties with multifocal IOLs. Dr. Rayes warned that macular surgery through multifocal IOLs may have narrow field of views, because the periphery of the IOL can be distorted.
Dr. Rayes asked the panels whether additional treatment is needed for iatrogenic posterior retinal breaks that may occur during ILM peeling. The panelists all answered that in the posterior pole, only PVD and ILM peeling are required, without the need of additional treatments such as photocoagulation. Dr. Rezaei commented that increasing the IOP immediately also prevents hemorrhage from oozing into the subretinal space.